Rationale and design of the TeleClinical Care Cardiac (TCC-Cardiac) trial: A pragmatic randomized trial of adjunctive virtual models of care in the secondary prevention of cardiovascular events

BACKGROUND

Digital health interventions have potential to improve outcomes in high risk cardiac patients through remote monitoring and patient education but introduce accessibility issues among patients who lack suitable smartphones. We will evaluate the effectiveness and scalability of the TeleClinical Care Cardiac (TCCCardiac) platform, that aims to reduce hospital readmissions and improve adherence to care.

METHODS

A pragmatic, all-comers trial with nested randomization, where patients being discharged home following an admission with acute myocardial infarction (MI) or decompensated heart failure (HF) are divided into 3 cohorts pragmatically, based on their access to technology. Cohort 1 participants are randomized to either the TCCCardiac model of care or usual care alone. The intervention includes a smartphone app, blood pressure monitor, weight scales, and a pulse oximeter, with remote monitoring of daily inputs by clinicians. Cohort 2 participants, with incompatible mobile phones, are randomized to receive educational content by SMS (TCC-Text) or usual care alone. Cohort 3 participants with no mobile phone receive usual care alone. The primary objective is to compare six-month readmission rates (primary end point) in Cohort 1. Secondary objectives include comparing the primary end point, evaluating the cost-effectiveness and overall impact across all cohorts and interventions, and process evaluation to understand the reach, adoption, and effectiveness of the full intervention. Follow-up includes 6-month interview for Cohort 1 and data linkage for all cohorts for 12-month outcomes.

RESULTS

The trial began in July 2021. Recruitment was slower than expected due to delays and interruptions related to COVID-19 and the final enrolment date was set for October 2023, by which time 873 participants had been enrolled: 553 in Cohort 1 (63.3%), 161 in Cohort 2 (18.4%), and 159 in Cohort 3 (18.2%). Data linkage is anticipated in May 2025, which includes a 6-month delay to ensure 12-month data will be available for all study patients, followed by the analysis of results.

CONCLUSIONS

TCCCardiac is the first large-scale study to assess smartphone-based messaging and remote monitoring in high-risk cardiac patients post-hospitalization. The study's pragmatic design and process evaluation aim to enhance future implementation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number ACTRN12621000754842.

HELicobacter Pylori screening to prevent gastrointestinal bleeding in patients with acute Myocardial Infarction (HELP-MI SWEDEHEART) - Design and rationale of a cluster randomized, crossover, registry-based clinical trial

BACKGROUND

The role of Helicobacter pylori (H. pylori) screening and eradication on reducing upper gastrointestinal bleeding (UGIB) complications after acute myocardial infarction (MI) is uncertain. The HELicobacter pylori screening to prevent gastrointestinal bleeding in patients with acute MI (HELP-MI SWEDEHEART) trial aims to determine whether systematic H. pylori screening compared to usual care reduces UGIB, mortality, and cardiovascular outcomes after MI.

METHODS

A cluster randomized, crossover, registry-based clinical trial using SWEDEHEART as trial platform for study population definition and source for data collection in combination with nationwide Swedish health data registries. Thirty-five Swedish hospitals, organized into 18 clusters based on percutaneous coronary intervention networks, were randomized to either routine H. pylori screening for adults with acute type-1 MI or usual care. After 1 year, a 2-month blanking period was followed by a crossover to the alternate allocation for 1 year. The trial enrolment was concluded after one additional year of registry-based follow-up. The primary endpoint is UGIB. Secondary endpoints include all-cause death, cardiovascular death, readmission for MI, stroke, or heart failure. Endpoints will be reported combined (Net Adverse Clinical Events; Major Adverse Cardiac or Cerebrovascular Events) and separately. The primary analysis will include all available follow-up time corresponding to a maximum follow-up time of 3 years and 2 months.

CONCLUSION

HELP-MI SWEDEHEART aims to determine the utility of routine H. pylori screening to reduce UGIB and improve cardiovascular outcomes after MI. By integrating national registry follow-up data with a pragmatic trial design, it has the potential to provide evidence for the effect of the implementation of routine H. pylori screening as part of acute MI care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05024864.

Ischemic and non-ischemic myocardial injuries at autopsy- an overview for forensic pathologists

Cardiovascular diseases are major causes of morbidity and death worldwide, and most cardiac deaths are related to ischemic injury of the myocardium (myocardial infarction). As underlined in the current clinical definition and classification of myocardial infarctions, not all myocardial injuries are due to ischemia: irreversible injury, ending in necrosis, can be induced also by various other factors, such as infections, immune disorders, physical and chemical agents, and trauma. This is supported by clinical studies showing that elevated serum levels of cardiac troponins, as a measure of myocardial damage, are also a common finding in the non-ischemic types of myocardial injury. Forensic pathologists confronted with autopsy findings suggestive of myocardial injury should therefore realize that both ischemic and non-ischemic forms of myocardial death can be observed, and not only in natural but also non-natural deaths (intoxications, asphyxia, traumatic and iatrogenic deaths, and others). Distinguishing these different types of injuries and underlying diseases or circumstances of death is critical, not only to determine the cause and mechanism of death, but also to help investigate often challenging medico-legal scenarios. This article reviews the broad spectrum of ischemic and non-ischemic myocardial injuries in natural and violent deaths. From this perspective we propose a diagnostic approach to myocardial injuries in a forensic pathology context.

Advancements and challenges in high-sensitivity cardiac troponin assays: diagnostic, pathophysiological, and clinical perspectives

Although significant progress has been made in recent years, some important questions remain regarding the analytical performance, pathophysiological interpretation and clinical use of cardiac troponin I (cTnI) and T (cTnT) measurements. Several recent studies have shown that a progressive and continuous increase in circulating levels of cTnI and cTnT below the cut-off value (i.e. the 99th percentile upper reference limit) may play a relevant role in cardiovascular risk assessment both in the general population and in patients with cardiovascular or extra-cardiac disease. International guidelines recommend the use of standardized clinical algorithms based on temporal changes in circulating cTnI and cTnT levels measured by high-sensitivity (hs) methods to detect myocardial injury progressing to acute myocardial infarction. Some recent studies have shown that some point-of-care assays for cTnI with hs performance ensure a faster diagnostic turnaround time and thus significantly reduce the length of stay of patients admitted to emergency departments with chest pain. However, several confounding factors need to be considered in this setting. A novel approach may be the combined assessment of laboratory methods (including hs-cTn assay) and other clinical data, possibly using machine learning methods. In the present document of the Italian Study Group on Cardiac Biomarkers, the authors aimed to discuss these new trends regarding the analytical, pathophysiological and clinical issues related to the measurement of cardiac troponins using hs-cTnI and hs-cTnT methods.

Clinical impact of cardiac magnetic resonance imaging in myocardial infarction with non-obstructive coronary arteries: a prospective multicentre cohort study

BACKGROUND

Cardiac magnetic resonance (CMR) may radiologically identify or confirm underlying pathophysiologies in myocardial infarction with non-obstructive coronary arteries (MINOCA), however, there are scant prospective data evaluating the impact on routine clinical care.

METHODS

In a multicentre international cohort study of MINOCA, clinical diagnosis, diagnostic certainty and intended clinical management were prospectively determined before and again after CMR. The primary outcome was a composite of change in clinical diagnosis and/or management. Secondary outcomes were individual components of the primary outcome, change in diagnostic certainty and number-needed-to-test for deprescription of dual antiplatelet therapy (DAPT). Predictors of the primary outcome were evaluated by multivariable logistic regression analysis.

RESULTS

In 320 patients, CMR was associated with change in diagnosis and/or management in 63% (95% CI 57% to 68%, p<0.001) and significantly increased diagnostic certainty (8/10 post-CMR (5-9) vs 6/10 pre-CMR (4-7), p<0.0001). Relevant predictors of the primary outcome on multivariable analysis were early CMR (≤14 days), absence of atheroma on coronary angiography and significant pre-CMR diagnostic uncertainty (≤5/10); CMR changed diagnosis and/or management in 80% of individuals with all three predictors versus 40% in those with none. In individuals where treating physicians initially chose to prescribe DAPT despite no obstructive culprit lesion, number-needed-to-test by CMR for DAPT deprescription was 3.

CONCLUSIONS

CMR in MINOCA is associated with significant changes in clinical diagnosis, diagnostic certainty and management. The impact on deprescription of unnecessary DAPT could have important implications for patient safety and costs and warrants further evaluation. Early CMR should be considered to augment diagnosis and management in MINOCA.

TRIAL REGISTRATION NUMBER

ISRCTN75233845.

Impact of age on cardiac troponin concentration among healthy individuals

BACKGROUND

The 99th percentile of cardiac troponin (cTn) among healthy individuals is the diagnostic cutoff for myocardial infarction. This study investigates the effect of age on the 99th percentile of cTn among healthy individuals.

METHODS

We sampled healthy Danish blood donors, screened using hemoglobin A1c, N-terminal pro-brain natriuretic peptide, and creatinine. The cTn assays investigated were Siemens Atellica and Dimension Vista hs-cTnI, Abbott hs-cTnI, Vitros hs-cTnI, and Roche hs-cTnT. The 99th percentiles were calculated using the non-parametric method and modeled using quantile regressions adjusted for sex and creatinine concentration.

RESULTS

We included 2287 participants, excluding 118 due to a history of heart disease, insufficient plasma, or biomarker screening, leaving 2169 participants with a median age of 58 years (IQR 49-69 years), and 1152 (53 %) were female. Concentrations increased with age for all assays (p < 0.001). Only the 99th percentile of hs-cTnT was significantly associated with age (0.42 ng/L increase/year, p < 0.001); for participants >70 years, the 99th percentile was 36.8 ng/L (90 % CI 33.8-40.7 ng/L), with 22.2 % above the manufacturer's 99th percentile. The difference in the 99th percentile between age groups was less clear for cTnI, except for the Vitros assay: <50 years 6.5 ng/L (90 % CI 5.0-26.9 ng/L) vs >70 years 17.3 ng/L (90 % CI 9.7-33.2 ng/L).

CONCLUSIONS

Age was associated with increased cTn concentrations for all assays. The correlation was strongest for hs-cTnT, where the 99th percentile for participants >70 years was more than double compared to those <50 years, with over 20 % exceeding the manufacturer's 99th percentile.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT05336435.

From the Cardiovascular-Kidney-Metabolic Disorders to the Atherosclerotic Cardiovascular Diseases: Their Prevalence Rates and Independent Associations in the SIMETAP Study

Background/Objectives: Atherosclerotic cardiovascular diseases (ASCVDs) remain the leading cause of morbimortality worldwide. The objectives of this study were to update the prevalence rates of ASCVDs and to evaluate their relationship with cardiovascular-kidney-metabolic (CKM) disorders. Methods: This cross-sectional observational study included 6588 adults selected through a simple random population-based sample from the Health Service database of the Madrid Region (Spain). Adjusted prevalence rates were calculated by the direct method, according to Spanish population data from the National Institute of Statistics. The relationships of CKM disorders with coronary heart disease (CHD), stroke, peripheral arterial disease (PAD), and ASCVD were assessed by bivariate and multivariate analyses. Results: The age- and sex-adjusted prevalence rates among overall adults with CHD, stroke, PAD, and ASCVD were 3.8%, 3.0%, 1.8%, and 7.3%, respectively, and they reached 5.6%, 4.4%, 2.6%, and 10.8%, respectively, among people aged 40 years and older. The prevalence rates were higher in men than women aged over 40 years for CHD and ASCVD, between 50 and 69 years for stroke, and aged over 60 years for PAD. The mean ages of women and men with ASCVD were 74.9 and 70.2 years, respectively. Hypertension, heart failure (HF), hypercholesterolaemia, diabetes, low eGFR, atrial fibrillation (AF), prediabetes, and low HDL-c were independently associated with ASCVD, highlighting hypertension and HF for all of them, in addition to hypercholesterolaemia for CHD and stroke, and specifically, AF for stroke. Conclusions: More than one in ten people aged over 40 suffer from CHD, stroke, or PAD. Hypertension, HF, hypercholesterolaemia, diabetes, and low eGFR are the major CKM disorders associated with ASCVD.

Navigating Electrocardiographic Risk Stratification and Therapeutic Strategies in Acute Coronary Syndrome Without ST-Segment Elevation

Of the patients suffering acute proximal left anterior descending (LAD) artery occlusion, a small but not insignificant minority does not manifest the classical ST-segment elevation myocardial infarction (STEMI) electrocardiographic (ECG) patterns. They manifest junctional upsloping ST-segment depression followed by tall, symmetrical T waves in the precordial leads instead, known as the de Winter pattern. Such patients may suffer a nearly transmural infarct if not managed promptly with percutaneous coronary intervention (PCI). Therefore, they should be treated as suffering a STEMI equivalent. The patient presented here suffered a total proximal "wrap-around" LAD artery in-stent occlusion manifesting the de Winter ECG pattern. The latter, was correctly and promptly recognized and the patient was managed successfully with emergency PCI achieving a good outcome. Discussion pertains to the morphology of ST-segment depression (STD) and the polarity and magnitude of the T waves accompanying STD which provide prognostic information and facilitate risk stratification in patients presenting with non-ST-segment elevation acute coronary syndrome. The pathophysiology underlying the de Winter ECG pattern and the appropriate therapeutic strategy are also discussed. The Littmann concept is also discussed, providing a reliable explanation for the ST-segment elevation observed in a misplaced lead V1.

Propensity score analysis of very long-term outcome after coronary thrombus aspiration in acute myocardial infarction

BACKGROUND

The long-term prognostic impact of thrombus aspiration (TA) in acute myocardial infarction (AMI) is unclear.

AIM

To assess the long-term prognostic impact of TA in AMI.

METHODS

Data were obtained from three nationwide French surveys (FAST-MI 2005, 2010 and 2015) including consecutive patients with AMI. Long-term death rate (up to 10 years) was assessed according to use of TA in patients with AMI treated with percutaneous coronary intervention (PCI).

RESULTS

TA was used in 1781/9654 patients (18%; 2005, 7%; 2010, 27%; 2015, 18%), including 1546 (86.8%) with ST-segment elevation myocardial infarction. Patients who had TA were younger (61 vs. 65 years; P<0.001), mostly men (81 vs. 74%; P<0.001) and their culprit lesion was more often on the right coronary artery (40 vs. 31%; P<0.001). Crude very long-term mortality was lower with TA (25.0 vs. 32.5%; crude hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.68-0.82; P<0.001). Adjusting on a propensity score (PS) for getting TA, very long-term mortality did not differ (HR 1.03, 95% CI 0.89-1.20; P=0.67). In-hospital stroke was more frequent with TA (0.7 vs. 0.4%; P=0.04). After PS matching (two cohorts, 1430 patients in each), very long-term mortality was similar in the two PS-matched cohorts (HR 1.02, 95% CI 0.87-1.19; P=0.84). In patients with a high thrombus burden, the adjusted HR for very long-term mortality was 0.76 (95% CI 0.59-0.98; P=0.03) in favour of TA.

CONCLUSIONS

These routine-practice data show that TA use increased until 2010 and declined thereafter, in keeping with international guidelines. In the overall population of patients with AMI who underwent PCI, TA had no effect on long-term survival. In those with a high thrombus burden, TA was associated with improved long-term survival.

Identification of patients with suspected NSTE-ACS in the observe zone: evaluating GRACE 1.0 score and a biomarker panel for risk stratification and management optimization

BACKGROUND

Current guidelines recommend additional diagnostic work-up for patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) triaged in the observe zone using accelerated diagnostic protocols. This study assessed the effectiveness of combining the Global Registry of Acute Coronary Events (GRACE) 1.0 score with additional non-cardio-specific biomarkers for risk stratification in the observe zone.

METHODS

A total of 6789 patients with suspected NSTE-ACS were enrolled over 24 months, with 961 (21.8%) assigned to the observe zone. A classification and regression tree (CART) analysis dichotomized risk using the GRACE-score and additional biomarkers beyond high-sensitivity cardiac troponin including C-reactive protein < 10 mg/dL, N-terminal pro-B-type natriuretic peptide < 300 ng/L, D-dimers < 5 mg/L, estimated glomerular filtration rate > 30 mL/min/1.73m2, Copeptin < 10 pmol/L, and hemoglobin > 10 g/dL. The primary endpoint was 1-year all-cause mortality, validated using the Biomarkers in Acute Cardiac Care (BACC) cohort.

RESULTS

A low GRACE 1.0 score < 109 points was found in 37.6% of observe zone patients, showing a negative predictive value of 98.6% and sensitivity of 89.8% for death. Adding biomarker information reduced predicted 1-year-mortality from 1.38% with the GRACE-score alone to 0.46% when none of the biomarkers were above cutoff (prevalent in 22.7%). The proportion of protocol-eligible patients increased from 22.7 to 37.6%, with no events within 30 days. Findings were confirmed in the BACC cohort.

CONCLUSION

A low GRACE 1.0 score combined with ≤ 1 elevated biomarker significantly improves mortality prediction in the observe zone, helping identify low-risk patients for further out-of-hospital diagnostic work-up, potentially decongesting crowded emergency departments. Registration URL: https://www.

CLINICALTRIALS

gov ; Unique identifier: NCT05774431.

Long-term outcome of patients presenting with myocardial injury or myocardial infarction

AIMS

Patients with acute or chronic myocardial injury are frequently identified in the context of suspected myocardial infarction (MI). We aimed to investigate their long-term follow-up.

METHODS AND RESULTS

We prospectively enrolled 2714 patients with suspected MI and followed them for all-cause mortality and a composite cardiovascular endpoint (CVE; cardiovascular death, MI, unplanned revascularization) for a median of 5.1 years. Final diagnoses were adjudicated by two cardiologists according to the Fourth Universal Definition of MI, including 143 (5.3%) ST-elevation MI, 236 (8.7%) non-ST-elevation MI (NSTEMI) Type 1 (T1), 128 (4.7%) NSTEMI T2, 86 (3.2%) acute and 677 (24.9%) with chronic myocardial injury, and 1444 (53.2%) with other reasons for chest pain (reference). Crude event rates per 1000 patient-years for all-cause mortality were highest in patients with myocardial injury (81.6 [71.7, 92.3]), and any type of MI (55.9 [46.3, 66.7]), compared to reference (12.2 [9.8, 15.1]). Upon adjustment, all diagnoses were significantly associated with all-cause mortality. Moreover, patients with acute (adj-HR 1.92 [1.08, 3.43]) or chronic (adj-HR 1.59 [1.16, 2.18]) myocardial injury, and patients with NSTEMI T1 (adj-HR 2.62 [1.85, 3.69]) and ST-elevation MI (adj-HR 3.66 [2.41, 5.57]) were at increased risk for cardiovascular events.

CONCLUSION

Patients with myocardial injury are at a similar increased risk for death and cardiovascular events compared to patients with acute MI. Further studies need to determine appropriate management strategies for patients with myocardial injury.

REGISTRATION

Clinicaltrials.gov (NCT02355457).

Limited incremental value of growth differentiation factor 15 in the initial evaluation of low and intermediate risk acute chest pain patients

INTRODUCTION

Expression of the cytokine growth differentiation factor 15 (GDF-15) is up-regulated in conditions of tissue injury and stress. We evaluated if GDF-15 predicts obstructive coronary artery disease (CAD) or need for revascularization within 30 days and 12 months in low/intermediate risk patients with acute chest pain.

MATERIALS AND METHODS

We included 537 hospitalized patients who had high-sensitivity troponin T (hs-cTnT) < 99th percentile and underwent coronary CT angiography (CCTA). Odds ratios (ORs) and 95 % confidence intervals (CI) were calculated by logistic regression analyses and are reported per standard deviation increment of GDF-15 (log-transformed).

RESULTS

The median (25th-75th percentile) age was 56 (49-65) years, 217 (40.4 %) were women, 83 (15.5 %) had obstructive CAD at CCTA. In total 49 (9.1 %) patients underwent revascularization within 30 days and 52 (9.7 %) within 12 months. In age and sex adjusted analysis GDF-15 was a significant predictor with ORs (95 % CI) of 1.35 (1.05-1.73), 1.39 (1.06-1.83) and 1.41 (1.07-1.84) for obstructive CAD, revascularization within 30 days and 12 months, respectively. However, after adjustment for clinical covariables, the ORs of GDF-15 were no longer statistically significant for either outcome (P ≥ 0.07). Adding hs-cTnT levels alone to the age and sex adjusted model also rendered the ORs of GDF-15 non-significant (P ≥ 0.31).

CONCLUSIONS

In patients with acute chest pain but without acute myocardial infarction, GDF-15 did not substantially improve the identification of obstructive CAD or need for revascularization within 30 days and 12 months. Our findings question the clinical usefulness of GDF-15 for prognostication of low-risk patients with acute chest pain.

The relationship of serum lactate level with in-hospital mortality after transcatheter aortic valve implantation

BACKGROUND

This study assesses the influence of early hyperlactatemia after the transcatheter aortic valve implantation (TAVI) procedure on subsequent outcomes.

METHODS

Adult patients undergoing elective percutaneous TAVI between 2012 and 2022 in a single tertiary cardiac center were retrospectively included. Peak post-procedure lactate level within 24-h was recorded for 284 patients included in the study. The primary outcome measured was 30-day mortality.

RESULTS

19 patients (6.6%) experienced 30-day mortality. Patients with mortality were characterized by advanced age (p = 0.022) and higher lactate levels after the procedure (5.4 ± 5.4 mmol/L vs 1.3 ± 0.6 mmol/L, p < 0.001). Post-procedure hyperlactatemia was an independent predictor of mortality (OR 3.95, 95% CI 1.35-11.60, p = 0.012). ROC analysis revealed 1.54 mmol/L as a cutoff for mortality with 85.7% specificity and 68.4% sensitivity.

CONCLUSION

The initial 24-hour lactate levels seem to play a valuable role in predicting the likelihood of surviving during the hospital stay after the implantation procedure. Further investigation is required to ascertain the optimal strategies for managing early post-procedure hyperlactatemia in the TAVI population.

Correlation of greyzone fibrosis compared to troponin T and late gadolinium enhancement with survival and ejection fraction in patients after acute myocardial infarction

AIMS

To quantify greyzone fibrosis (GZF) in patients after acute myocardial infarction (MI) and to evaluate its correlation with MI-free survival and improvements in left ventricular ejection fraction (LVEF) compared with the established risk factors high-sensitivity cardiac troponin T (hs-cTnT) and Late Gadolinium Enhancement (LGE).

METHODS AND RESULTS

The study involved 176 patients who experienced acute MI and underwent cardiac magnetic resonance (CMR) prior to hospital discharge, followed by a second CMR on average six months later. LGE was quantified in both examinations, a separate analysis of the GZF was conducted only in the follow-up CMR after resolution of the initial infarct edema. LVEF was measured in both CMR. hs-cTnT levels were assessed at hospital admission, as well as 8, 16, 24, 48 and 72 h after coronary intervention. Telephone follow-ups were conducted annually for up to 8 years. LGE measurements showed better correlation with MI-free survival (Harrell's C of 0.711 of LGE mass) compared to GZF (0.579 of GZF mass). Additionally, hs-cTnT outperformed GZF (Harrell's C of 0.645). As an univariable predictor for MI-free survival, only hs-cTnT reached significance (p < 0.05). With regard to improvements in ejection fraction, both hs-cTnT and LGE measurements showed acceptable correlation with improvement in ejection fraction (p < 0.05), while GZF measurements showed no correlation (p > 0.5).

CONCLUSIONS

In CMR, the assessment of GZF demonstrated inferior p correlation compared to hs-cTnT and LGE in patients after acute MI with respect to the endpoint of MI-free survival. Furthermore, GZF showed no correlation with the improvement of LVEF.

Long-term risk factor management and adverse events in patients with early-onset myocardial infarction-a "real-world" study

BACKGROUND

International guidelines emphasize the importance of preventive efforts after early-onset myocardial infarction (EOMI); however, data on "real-world" long-term risk factor management and adverse event rates in this special patient group is scarce.

METHODS

In this German registry study, 301 patients with MI aged ≤ 45 years were investigated. Risk factor control was assessed at the time of index MI and after 1 year. Major adverse cardiac and cerebrovascular events (MACCE) and its predictors were analyzed during long-term follow-up (median duration 49 months).

RESULTS

A majority of patients with EOMI presented with insufficient risk factor control, even during 1-year follow-up. After 1-year 42% of patients were persistent smokers; 74% were physically inactive. The rate of obesity increased significantly from index MI (41%) to 1-year follow-up (46%, p = 0.03) as well as the rate of dysglycemia (index MI: 40%; 1-year follow-up: 51%, p < 0.01) and diabetes mellitus (index MI: 20%; 1-year follow-up: 24%, p < 0.01). 66% of the patients with diabetes mellitus had unsatisfactory HbA1c after 1 year; 69% of the patients did not attain guideline-recommended lipid targets. The rate of MACCE during long-term follow-up was 20% (incidence rate 0.05 per person-year). In a multivariable analysis smoking (HR 2.2, HR 1.3-3.7, p < 0.01) and physical inactivity (HR 2.8, HR 1.2-6.7, p = 0.02) were significant predictors for the occurrence of MACCE.

CONCLUSION

Insufficient long-term risk factor control was common in patients with EOMI and was associated with an elevated rate of MACCE. The study reveals that better strategies for prevention in young patients are crucially needed.

Effect of constipation on hospitalization due to heart failure in patients after myocardial infarction: a retrospective cohort study

BACKGROUND

Patients with constipation after acute heart failure (HF) are at high risk of rehospitalization due to HF. Although HF after myocardial infarction (MI) affects patient outcomes, the relationship between constipation and patient prognosis after MI remains unclear. In this study, we evaluated the effects of constipation on the prognosis of patients with MI, focusing on hospitalization due to HF.

METHODS

We investigated 1,324 patients with MI admitted to our hospital between January 2012 and December 2023 (mean age, 68 ± 14 years; 76% males). Patients with constipation were defined as those using laxatives regularly.

RESULTS

During the follow-up period (median, 2.7 years), 115 patients died, and 99 were re-hospitalized due to HF. Landmark Kaplan-Meier analyses revealed incidences of 7.8% and 2.1% hospitalization due to HF from 0 to 0.5 years (log-rank: p < 0.0001) and 4.8% and 3.9% from 0.5 to 3 years (log-rank: p = 0.17) among patients with and without constipation, respectively. The adjusted Cox proportional hazards analysis revealed a significantly higher risk of hospitalization due to HF from 0 to 0.5 years in patients with constipation than in those without it (hazard ratio, 2.12; 95% confidence interval, 1.07-4.19; p = 0.032). However, no significant difference was found from 0.5 to 3 years (hazard ratio, 0.86; 95% confidence interval, 0.47-1.57; p = 0.63).

CONCLUSIONS

Constipation was strongly associated with a higher risk of hospitalization due to HF in patients with MI during the first 6 months after discharge.

Cocaine-induced acute myocardial infarction: angiographic features and outcomes

BACKGROUND

Cocaine is a global health burden and the cause of a significant number of emergency department consultations. Its association with acute myocardial infarction (AMI) is known, however, data are still rare. The aim of this study was to define causative pathologies behind cocaine-induced AMI (CI-AMI) and to analyze their clinical features.

METHODS

Patients with the diagnosis of CI-AMI were retrospectively identified at the University Hospital Zurich between 1997 and 2023. The angiograms were reviewed to confirm the diagnosis. Coronary microvascular dysfunction (CMD) was separately evaluated by an angiography-based analysis (AngioPlus Core, Microport Medical Co.). The primary endpoint was rates of major adverse cardiovascular events (MACE) at 30 days, 1 year, and 2 years.

RESULTS

Forty-five cases of CI-AMI were identified. Twelve patients (27%) were diagnosed with plaque rupture and intraluminal thrombus, eight (18%) with coronary artery disease (CAD) without thrombus formation, eight (18%) with spontaneous coronary artery dissection, six (13%) with CMD, four (9%) with coronary vasospasm, and four patients (9%) with Takotsubo syndrome. The cause of CI-AMI remained unclear in three patients (6%). No clinically useful predictors of CAD were identified. 91% of patients had values associated with CMD during angiography-based analysis, independently from the etiology of CI-AMI. 49% of cases were treated by revascularization, and the number of MACE was high (16%, 28%, and 34% at 30 days, 1 year, and 2 years).

CONCLUSIONS

CI-AMI is a rare, but important cause of acute coronary syndromes (ACS). CAD represents the most frequent etiology of AMI, but there is a broad range of other entities. Patients suffer from a significant number of adverse events.

Increased Thrombogenicity is Associated With Coronary Microvascular Dysfunction in Patients With STEMI-A Proof-of-Concept Study

BACKGROUND

Up to 50% of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) develop coronary microvascular dysfunction (CMD).

AIMS

This study aims to assess whether a prothrombotic state of coronary blood, defined by thromboelastography (TEG), is associated with post-pPCI CMD in STEMI.

METHODS

TEG analysis of infarct-related coronary artery (IRA) blood was performed in 25 consecutive STEMI patients before and after successful pPCI. CMD was defined by high values of the angiography-derived index of microcirculatory resistance (IMRangio ≥ 40 units).

RESULTS

The median age was 59 (IQR 51-71) years. CMD was observed in 13 (52%) patients. Pre-pPCI Reaction (R) and Kinetic (K) time of the coronary blood from the IRA were inversely correlated with IMRangio (rho -0.45, p = 0.02; rho -0.62, p = 0.002 respectively). R time was significantly shorter in patients who developed CMD (10.7 [IQR 8.8, 13.1] vs. 18.2 [IQR 12.6, 24.2], p = 0.05), and it provided an overall good diagnostic accuracy in predicting CMD (AUC 0.75, [95% CI 0.53-0.96] p = 0.05). Similar relationship was founded for K time: 3.5 [IQR 2.2-4.6] versus 10.6 [IQR 4.5-30.0] min, p = 0.01; AUC 0.82, [95% CI 0.64-0.99] p = 0.01. Moreover, α angle was significantly larger (57.4 [IQR 46.5-64.8] vs. 40.0 [IQR 39.0-49.5], p = 0.03) in patients with CMD (AUC 0.78, [95% CI 0.57-0.98], p = 0.03). Coronary post-pPCI TEG parameters were not associated with CMD.

CONCLUSIONS

In this proof-of-concept study, a prothrombotic state of coronary blood from the IRA is associated with CMD. Further studies are warranted to evaluate if TEG may enhance individualized therapies in patients with STEMI at risk of CMD.

Antiplatelet therapy following conservatively managed spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a relatively uncommon but increasingly recognized etiology of acute coronary syndrome (ACS). Conservative management is generally recommended, but optimal medical therapy is unknown. The majority of patients are discharged on dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor based on trials and guidelines developed for ACS caused by plaque rupture and subsequent platelet activation and aggregation. Observational trials have shown conflicting results on the effects of antiplatelet therapy on major adverse cardiac events after SCAD. This manuscript provides a review of the available data, including a meta- analysis, and offers recommendations for antiplatelet therapy after conservatively managed SCAD in clinical practice.

Identification and validation of m7G-related genes related to macrophage immunity in acute myocardial infarction through comprehensive bioinformatics analysis

BACKGROUND

Acute myocardial infarction (AMI) is a fatal disease related to immune cell activation; however, the pathological molecular mechanisms associated with AMI and immunity remain unclear. This study aims to explore m7G-related hub genes associated with immune cell characteristics in AMI through the bioinformatics method.

METHODS

Transcriptome sequencing data downloaded from GSE59867 (GPL6244) were used to screen m7G-related differentially expressed genes (DEGs) between AMI and non-AMI controls. Abnormal immune cell characteristics was analyzed by single-sample gene set enrichment analysis (ssGSEA) algorithm. Hub genes were screened from m7G-related DEGs by the support vector machine recursive feature elimination (SVM-RFE) algorithm and random forest tree model. The association of hub genes with immune cell types was analyzed by GSEA and Spearman correlation analysis. A mouse AMI model and hypoxia-stimulated macrophage model were established to verified the function of CYFIP1 on macropahges.

RESULTS

We identified significant differences in 21 types of immune cells and 13 m7G-related DEGs between AMI and non-AMI controls. m7G-related DEGs were enriched in nucleoside nuclear catabolism, RNA modification and translation regulation, the HIF-1 signaling pathway, etc. 111 AMI samples were divided into three clusters based on the cluster analysis of m7G-related DEG expression profiles, and immune cell types were significantly different in the three clusters. Four hub genes including CYFIP1, EIF4E2, IFIT5, and NCBP3 were screened and positively or negatively correlated with AMI. ROC curve verified the efficiency of the 4 hub genes in the diagnosis prediction models of AMI. CYFIP1 had the best prediction efficiency of than other 3 hub genes. GESA enrichment and Spearman correlation analysis found that hub genes were associated with inflammation and immune, especially CYFIP1 had a strong statistical relationship with macrophages, Monocyte, etc. By experiments, we found that CYFIP1 was upregulated in AMI patients and animal models, and knockdown of CYFIP1 inhibited hypoxia-mediated macrophage inflammatory response.

CONCLUSION

m7G-related hub genes are associated with immune cell characteristics in AMI, among which CYFIP1 may play a key role in the regulatory network of macrophage immune response.

Safety and efficacy of low-temperature RA-flush solution in patients with moderate-to-severe calcified lesions (LOTA-II): a randomized, double-blind, multicenter study

Rotational atherectomy (RA) is an effective, mature, and specific treatment for calcified lesions. However, the incidence of RA-related myocardial injury remains high and has not been adequately addressed. To assess the safety and efficacy of low-temperature RA-flush solution versus room-temperature RA-flush solution during RA. A total of 132 patients with moderate-to-severe calcified lesions who underwent RA were randomly assigned to the low-temperature RA-flush solution group or the room-temperature RA-flush solution group. The primary endpoint was RA-related myocardial injury, defined as any increase in myocardial biomarkers within 72 h after percutaneous coronary intervention (PCI). Secondary endpoints included RA-related myocardial infarction (MI), RA-related transient slow/no flow, or transient coronary spasm. A total of 78 patients (59.1%) had increased cardiac troponin I (cTnI) levels, and 60 patients (45.5%) had increased creatine kinase isoenzyme (CK-MB) levels after PCI. The number of patients with myocardial injury (primary endpoint), defined as elevated cTnI (47.0% vs. 71.2%, p = 0.005) or elevated CK-MB (28.8% vs. 62.1%, p < 0.001), was significantly lower in the low temperature group than in the room temperature group. The number of patients with RA-related transient slow/no flow (6.1% vs. 34.8%, p < 0.001) and transient coronary spasm (9.1% vs. 25.8%, p = 0.012) (secondary endpoints) was significantly lower in the low temperature group than in the room temperature group; no significant difference in the incidence of RA-related MI was observed between the two groups. Compared with room-temperature RA-flush solution, low-temperature RA-flush solution is associated with reduced RA-related myocardial injury in patients treated with RA.Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03701230; first submitted registration date: 09/10/2018.

Derivation and Validation of ESC-0/1-h Algorithm for High-Sensitivity Troponin T and I in Cancer Patients

BACKGROUND

The diagnostic performance of high-sensitivity cardiac troponin T/I (hs-cTnT/I) and the efficacy of the European Society of Cardiology (ESC) 0/1-h hs-cTnT/I algorithms for the early diagnosis of non-ST-elevation myocardial infarction are lower in cancer patients.

OBJECTIVES

The authors aimed to derive new cutoffs for ESC 0/1-h hs-cTnT/I algorithms optimized for use in patients with active or past cancer.

METHODS

Patients presenting with suspected non-ST-elevation myocardial infarction to the emergency department enrolled in an international multicenter study were analyzed. Final diagnoses were centrally adjudicated by 2 independent cardiologists according to the fourth universal definition of myocardial infarction. External validation was performed in 2 independent cohorts.

RESULTS

Among 541 eligible cancer patients, cancer-optimized ESC 0/1-h hs-cTnT cutoffs, <8 ng/L at presentation (if chest pain onset >3 hours) or <14 ng/L if 0/1 h-delta is <3 ng/L for rule-out and ≥54 ng/L or 0/1-h delta ≥4 ng/L for rule-in, increased the efficacy vs the current cutoffs from 58.6% (95% CI: 54.4-62.7) to 68.0% (95% CI: 64.0-71.8; P < 0.001). Sensitivity and specificity remained high and comparable. Similarly, among 516 eligible patients, cancer-optimized ESC 0/1-h hs-cTnI-Architect cutoffs, <7 ng/L at presentation (if chest pain onset >3 hours) or <10 ng/L if 0/1-h delta is <3 ng/L for rule-out and ≥61 ng/L or 0/1-h delta ≥5 ng/L for rule-in, increased the efficacy vs the current cutoffs from 59.3% (95% CI: 55.0-63.5) to 78.9% (95% CI: 75.2-82.2; P < 0.001). Sensitivity and specificity again remained high and comparable. Findings were confirmed in internal and external validation cohorts (n = 130 and n = 195 patients, respectively).

CONCLUSIONS

Cancer-optimized ESC 0/1-h hs-cTnT/I algorithm cutoffs increased efficacy maintaining high safety.

Association of Atrial Fibrillation Burden With Cardiovascular Outcomes in New-Onset Atrial Fibrillation Complicating Myocardial Infarction

BACKGROUND

New-onset atrial fibrillation (NOAF) is a common complication after acute myocardial infarction (AMI) and is associated with poor survival. Atrial fibrillation (AF) burden is used to characterize the severity of AF. However, the association of AF burden with cardiovascular outcomes in NOAF complicating AMI is poorly understood. We aimed to investigate the prognostic impact of AF burden in NOAF complicating AMI.

METHODS AND RESULTS

This multicenter retrospective cohort study included patients with AMI without a medical history of AF who developed the first documented AF during hospitalization between January 2014 and January 2022. AF burden was defined as the percentage of time spent in AF during hospitalization. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, reinfarction, or ischemic stroke. A total of 812 patients with AMI and NOAF (mean age, 72.7±10.9 years; 552 men) were included. An AF burden of 15.29% was identified as the cutoff value for prognostic stratification; 663 patients with complete follow-up data were then classified into the low-burden (AF burden <15.29%; n=447) and high-burden (AF burden ≥15.29%; n=216) groups. During a median of 4.2 years of follow-up, high AF burden was associated with an increased risk of the composite outcomes (hazard ratio [HR], 1.66 [95% CI, 1.30-2.12]; P<0.001) after multivariable adjustment. When measured as a continuous scale, increasing AF burden remained an independent predictor of the composite outcomes (HR, 1.06 per 10% AF burden [95% CI, 1.02-1.09]; P=0.004).

CONCLUSIONS

A greater burden of AF is associated with a higher risk of cardiovascular outcomes among patients with NOAF complicating AMI.

Nutritional risk score predicts the length of stay in patients undergoing coronary angiography

AIM

Nutritional status is a factor that impacts the clinical outcomes of various medical conditions, including cardiovascular disease and surgical procedures; however, little is known about its role in percutaneous procedures. This study aimed to assess the association between nutritional status and risk in patients undergoing coronary angiography and in-hospital mortality and length of stay to improve risk stratification and peri-procedural care.

METHODS

Patients who underwent coronary angiography between January 2022 and August 2023. Nutritional status was assessed with body mass index, and nutritional risk was assessed with the Nutritional Risk Screening 2002 score. Multivariate regression models assessed independent predictors of in-hospital mortality, adjusting for age, sex, coronary event, Canadian Cardiovascular Society class, and cardiac arrest at admission. Subgroup analyses were performed based on coronary event type to evaluate whether the associations differed across clinical presentations.

RESULTS

Patients who underwent angiography (n = 1343) were aged 69.2 ± 11.1 years, 51% male, and 49% had acute coronary syndrome. The mean length of stay at the hospital was 4.5 ± 4.8 days; 38% of patients stayed ≥5 days. The in-hospital mortality rate was 1.3%. Regression analyses revealed that the Nutritional Risk Screening 2002 score independently predicted the length of stay (β = 0.63, p = 0.002), and this relationship was strongest in the non-ST segment elevation myocardial infarction subgroup (β = 1.26, p = 0.02). Body mass index did not predict the length of stay. There was no significant relationship between in-hospital mortality and body mass index or the Nutritional Risk Screening 2002 score.

CONCLUSION

Nutritional risk significantly predicts the length of stay after coronary angiography, independent of age, sex, and coronary event type. Clinicians should consider routine nutritional risk assessment preceding coronary angiography to help individualise post-procedure, in-hospital care.

Evaluating the Efficacy of the Marburg Heart Score to Triage Patients Presenting With Chest Pain in an Emergency Department: A Prospective, Multicenter, Observational Study

Objective: Chest pain is a common complaint in emergency departments. Although most patients are admitted to emergency department intensive care, only 12% have acute coronary syndrome. An accurate, efficient score is needed to improve triage and prevent unnecessary referrals to emergency department intensive care. The Marburg Heart Score, validated to rule out acute coronary syndrome in primary care, is quick to administer and does not require test results. This study aims to assess whether the Marburg Heart Score is effective in a triage setting for patients presenting with chest pain in emergency departments. Method: This prospective, observational, multicenter study was conducted with triage nurses in four hospitals in France between July 15, 2018, and May 31, 2019. The primary endpoint was the negative predictive value of the Marburg Heart Score ≤ 2 for ruling out acute coronary syndrome. Acute coronary syndrome diagnosis was made using medical record data combined with a diagnosis from the physician in charge. Results: A total of 1045 patients were included. For a cutoff score of ≤ 2, the negative predictive value for suspected acute coronary syndrome was 95.6% (95% CI [94.0-97.2]) and the area under the curve was 0.603 (95% CI [0.521-0.685]). There were 28 false negatives, two of which were due to the score being completed incorrectly. Conclusion: This study reveals that the Marburg Heart Score is an efficient tool to direct patients presenting with chest pain and MHS < 2 to a conventional ED bed. This could potentially optimize triage in the emergency department to prevent overloading the emergency department intensive care.

Comparative Analysis of Single- and Dual-Marker Strategies for Rapid Non-ST-Segment-Elevation Myocardial Infarction Rule-Out Using Cardiac Myosin-Binding Protein C, Copeptin, and High-Sensitivity Cardiac Troponin T in the Emergency Department

BACKGROUND

This study compared the diagnostic and prognostic performance of various non-ST-segment myocardial infarction (NSTEMI) rule-out protocols, incorporating cardiac myosin-binding protein C (cMyBP-C), high-sensitivity cardiac troponin T (hs-cTnT), and Copeptin, both individually and as part of dual-marker strategies (DMSs) against the European Society of Cardiology 0/1-hour and 0/3-hour algorithms.

METHODS

We enrolled 1765 patients presenting to the emergency department with suspected NSTEMI. We evaluated biomarker algorithms including cMyBP-C (<10 ng/L, <2.3 ng/L), hs-cTnT (limit of blank [<3 ng/L], limit of detection [<5 ng/L], 99th percentile [≤14 ng/L]), and DMS combinations of copeptin (<10 pmol/L) with hs-cTnT, cMyBP-C with hs-cTnT, and copeptin with cMyBP-C. The European Society of Cardiology 0/1-hour and 0/3-hour algorithms were also tested. We calculated negative predictive values and sensitivities for NSTEMI rule-out and assessed effectiveness and prognostic performance based on cardiovascular events within 30 days and 1 year.

RESULTS

The areas under the curve were 0.922 for hs-cTnT, 0.917 for cMyBP-C, and 0.624 for copeptin in diagnosing NSTEMI. DMS protocols showed negative predictive values of 99.1% to 100%, comparable with the European Society of Cardiology algorithms (99.3%-100%). Sensitivities for DMS ranged from 96.2% to 100%. All protocols had low rates of the combined end point of cardiovascular events within 30 days (0.0%-0.6%).

CONCLUSIONS

The European Society of Cardiology 0/1-hour algorithm and DMS combining hs-cTnT with either cMyBP-C or copeptin provide highly reliable and safe protocols for NSTEMI rule-out. These DMS approaches offer promising alternatives to current standards, potentially improving clinical decision making and efficiency in emergency departments.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT06128317.

Validation of complex PCI criteria in drug-coated balloon angioplasty

BACKGROUND

Procedural complexity during percutaneous coronary interventions (PCI) with drug-eluting stent (DES) has been associated with adverse events, especially in case of long and multiple stents implantation.

OBJECTIVE

This study aims to validate contemporary complex PCI criteria for drug coated balloon (DCB)-based PCI.

METHODS

Consecutive patients undergoing DCB angioplasty at 2 Italian centers from 2018 to 2023 were retrospectively enrolled. Complex DCB-PCI was defined as the presence of at least 1 of the 6 following features: 3 vessels treated; ≥ 3 lesions treated; ≥ 3 devices (DES or DCB) used; bifurcation treated with 2 devices; total device length (DES + DCB) > 60 mm; CTO as target lesion. The primary endpoint was the 2 year incidence of target lesion failure (TLF), a composite of target lesion revascularization (TLR), target vessel-myocardial infarction and cardiac death, at time-to-first event analysis.

RESULTS

A total of 1279 patients were included, of whom 642 (50.2%) met complex PCI criteria. The most frequently met criteria was "total device length > 60 mm" (71.6% in the complex PCI group). The proportion of in-stent restenosis (ISR) was 30.8% in the complex DCB-PCI group and 43.8% in the non-complex PCI group (p < 0.001). After adjusting for relevant clinical covariates and for the presence of ISR, patients undergoing complex PCI had a higher incidence of TLF at 2 years as compared to those undergoing non-complex PCI (16.7 vs. 11.4%; adj. hazard ratio 1.73, 95% confidence interval 1.16-2.59, p = 0.007). However, such difference was significant only in the ISR subgroup, while outcomes of complex and non-complex PCI for de novo lesions were similar.

CONCLUSIONS

In a real-world cohort of patients undergoing DCB angioplasty, complex PCI criteria were frequently met and associated with higher risk of TLF. However, their prognostic impact was limited in patients with de novo coronary lesions treated with DCB.

Tirofiban efficacy and safety for percutaneous coronary intervention in patients with acute coronary syndrome: protocol for a systematic review and meta-analysis

INTRODUCTION

Percutaneous coronary interventions (PCI) have become a cornerstone in the management of acute coronary syndromes (ACS), yet they carry risks of complications like stent thrombosis and reinfarction. Glycoprotein IIb/IIIa inhibitors, particularly tirofiban, have been employed as adjunctive therapies to reduce these risks. Despite its potential benefits, the use of tirofiban remains a subject of debate, with varying recommendations across major clinical guidelines.

METHODS AND ANALYSIS

We systematically searched five databases from 1 January 1992 to 1 April 2025, including Medline, Embase, Lilacs, Clinicaltrials.org and Cochrane Central Register of Controlled Trials (CENTRAL), in addition to three grey literature databases. Randomised controlled trials and cluster randomised trials investigating the use of intravenous or intracoronary tirofiban in patients with ACS, unstable angina or myocardial infarction were considered for inclusion. Only published studies in English, Portuguese, Spanish and French were included. Data selection and extraction will be performed independently by two researchers, with any inconsistencies resolved with consensus or by consulting a third senior researcher. The risk of bias will be assessed through the risk of bias measurement tool (Rob-2) for interventions and/or cluster trials by two researchers independently, and the overall certainty of evidence will be assessed by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. A meta-analysis will be carried out if there is sufficient homogeneity between studies, with subgroup analysis being performed if significant heterogeneity is detected. Additionally, a metaregression model will be conducted if sufficient data are available.

ETHICS AND DISSEMINATION

As this study involves secondary analysis of published data, ethics approval is not required. The results will be disseminated through peer-reviewed publication, conference presentations and will be shared with relevant clinical guideline committees.

PROSPERO REGISTRATION NUMBER

CRD42024585252.

Prognostic Value of Angiography-Derived Index of Microcirculatory Resistance in Patients with Diabetes and ST-Segment Elevation Myocardial Infarction

BACKGROUND

The occurrence of coronary microvascular dysfunction (CMD) after primary PCI in patients with diabetes mellitus (DM) and ST-elevation myocardial infarction (STEMI), and its impact on prognosis remains elusive.

METHODS

This single-centre retrospective observational study included 293 patients diagnosed with DM and STEMI. The coronary-angiography-derived index of microvascular resistance (caIMR) was calculated using the measurement software FlashAngio (Suzhou Rainmed Medical Technology Company, Ltd, Suzhou, Jiangsu, China), whereas cardiac magnetic resonance parameters were quantified using the postprocessing software Cvi42. CMD was defined as caIMR ≥ 25 U. The primary endpoint was major adverse cardiac events (MACE), defined as all-cause mortality, nonfatal myocardial infarction, ischemia-driven revascularization, and heart failure.

RESULTS

MACE occurred in 86 patients (29.4%) during a median follow-up of 31 months. A significant correlation was identified between caIMR and both microvascular obstruction (MVO) (R = 0.61, P < 0.001) and infarct size (IS) (R = 0.39, P < 0.001). Furthermore, caIMR ≥ 25 was identified as an independent risk factor for MACE (hazard ratio [HR], 2.99; 95% confidence interval [CI], 1.78-5.03; P < 0.001). In addition, the integration of caIMR into risk modelling significantly improved prediction of MACE (net reclassification improvement 0.264, P < 0.001; integrated discrimination improvement 0.060, P < 0.001). Finally, the Kaplan-Meier survival curves displayed that patients with caIMR ≥ 25 were at a higher risk of MACE (log-rank P < 0.001).

CONCLUSIONS

The caIMR demonstrated a satisfactory correlation with CMR-determined MVO and IS in patients with DM and STEMI. Elevated caIMR was independently linked to a higher risk of MACE in patients with diabetes and STEMI post-PCI, serving as an effective predictor for MACE.

CLINICAL TRIAL REGISTRATION

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Development of a multidimensional prediction model for long-term prognostic risk in patients with acute coronary syndromes after percutaneous coronary intervention: A retrospective observational cohort study

BACKGROUND

The aim of this study is to examine the critical variables that impact the long-term prognosis of patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI) and to create a multidimensional predictive risk assessment model that can serve as a theoretical basis for accurate cardiac rehabilitation.

METHODS

The study involved ACS patients who received PCI at the First Hospital of Jilin University from June 2020 to March 2021. Participants were categorized into two groups: acute myocardial infarction (AMI) and unstable angina (UA), according to clinical data and angiographic findings. Hospitalization data, physical performance, exercise tolerance prior to discharge, average daily steps, major adverse cardiac events (MACE), and a follow-up period of 36 months were documented. The dates for accessing data for research purposes are February 10, 2022 (10/2/2022) to December 10, 2023 (10/12/2023).

RESULTS

We observed substantial increases in weight, fasting plasma glucose (FPG), total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), white blood cell (WBC) count, neutrophil granulocyte count, monocyte count, hemoglobin (Hb) levels, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels in the acute myocardial infarction (AMI) cohort relative to the unstable angina (UA) cohort. We found white blood cell count (WBC) (OR: 4.110) and the effective average number of daily steps (ANS) (OR: 2.689) as independent prognostic risk factors for acute myocardial infarction (AMI). The independent risk factors for unstable angina prognosis were white blood cell count (OR: 6.257), VO2 at anaerobic threshold (OR: 4.294), and effective autonomic nervous system function (OR: 4.097). The whole prognostic risk assessment score for acute myocardial infarction (AMI) is 5 points, with 0 points signifying low risk, 2-3 points representing intermediate risk, and 5 points indicating high risk. The overall prognostic risk assessment score for UA is 7 points, with 0-3 classified as low risk, 4-5 as intermediate risk, and 6-7 as high risk.

CONCLUSION

This study developed a multimodal predictive model that integrates the inflammatory response after onset, physical performance and exercise tolerance before discharge, and daily activity after discharge to predict the long-term prognosis of patients with ACS. The multidimensional model is more effective than the single-factor model for assessing risk in ACS patients. This work also establishes a theoretical basis for improving the prognosis of potentially high-risk individuals with accurate and reasonable exercise prescriptions.

Impact of Elevated Troponin Level at the Time of Sepsis Recognition on the Clinical Outcomes: A Propensity Score-Matched Cohort Study

BACKGROUND

Sepsis-induced cardiac dysfunction, known as septic cardiomyopathy, is a common complication associated with increased mortality. Cardiac troponins serve as markers for myocardial injury and are frequently elevated in patients with sepsis. However, the role of troponin elevation at sepsis recognition in risk stratification remains controversial.

METHODS AND RESULTS

This nationwide multicenter prospective cohort study analyzed 2141 adult patients with sepsis without prior cardiovascular disease from the Korean Sepsis Alliance registry. These patients were classified as having either elevated troponin levels or troponin levels in the normal range at the time of sepsis recognition, according to the reference ranges specific to each participating institution. The primary outcome was hospital mortality, and propensity score matching was used to control for confounding factors. In the propensity score-matched cohort (523 pairs), there were no significant differences in hospital mortality (35.2% versus 32.7%, odds ratio [OR], 1.12 [95% CI, 0.86-1.44], P=0.396), hospital length of stay (13.0 versus 15.0 days, OR, 1.00 [95% CI, 0.99-1.00], P=0.128), intensive care unit mortality (24.7% versus 25.0%, OR, 0.98 [95% CI, 0.74-1.30], P=0.886), or intensive care unit length of stay between the elevated troponin and control groups. However, landmark analysis revealed that the elevated troponin group had a lower survival probability after 1 week (log-rank P=0.033) and significantly higher kidney Sequential Organ Failure Assessment scores from intensive care unit admission to day 7 (P=0.003).

CONCLUSIONS

Troponin elevation at sepsis recognition was not significantly associated with increased hospital mortality or worse clinical outcomes in patients with sepsis.

Cardiac Troponin I and T Ratio and Risk of Cardiovascular or Non-Cardiovascular Events in a General Population

BACKGROUND

Emerging evidence suggests that the ratio between cardiac troponin (cTn) I and T may provide information on the risk of adverse outcomes in individuals with cardiovascular disease. Whether the cTn I/T ratio provides prognostic insights in the general population is unknown.

METHODS

The cTn I/T ratio was calculated in 8855 participants (43% female, median age 56 years) from the Generation Scotland Study where both cTnI and cTnT concentrations were above the limit of blank. Multivariable cause-specific Cox proportional hazard models were used to estimate the associations between cTn I/T ratio and the primary outcome of cardiovascular or non-cardiovascular death.

RESULTS

The median cTn I/T ratio was 0.5 (25th-75th percentile, 0.3-0.8) and median follow-up was 11.4 (10.8-12.7) years. Individuals in the highest ratio tertile (≥0.64) were more likely to be male, have a higher body mass index and systolic blood pressure, and a history of cardiovascular disease. Those in the lowest ratio tertile (<0.38) were more likely to be smokers or have diabetes. After adjustment for cardiovascular risk factors, the cTn I/T ratio was positively associated with cardiovascular death (per doubling increase, adjusted hazard ratio [HR] 1.16 [95% CI, 1.05-1.28]), while an inverse association was observed for non-cardiovascular death (HR 0.89 [95% CI, 0.81-0.99]).

CONCLUSIONS

The cTn I/T ratio is positively associated with cardiovascular death in the general population, while inversely associated with non-cardiovascular death. Future research is needed to unravel underlying mechanisms and determine whether the cTn I/T ratio provides valuable information regarding risk of cardiovascular and non-cardiovascular mortality to guide further management.

The effect of major abdominal surgery on the sublingual microcirculation: an observational study

PURPOSE

It remains unknown whether the sublingual microcirculation is impaired during noncardiac surgery. We, therefore, aimed to investigate the sublingual microcirculation in patients undergoing major abdominal surgery. Specifically, we sought to test the primary hypothesis that the sublingual microcirculation is persistently impaired during major abdominal surgery.

METHODS

In this prospective observational study, we assessed the sublingual microcirculation using vital microscopy before induction of general anesthesia, at the time of surgical incision, every 20 min during surgery, and on the first postoperative day in 46 patients undergoing major abdominal surgery. The primary endpoint was the area under a proportion of perfused vessels (PPV) of 92% as a measure of the duration and severity of capillary red blood cell flow impairment.

RESULTS

The median [interquartile range (IQR)] intraoperative area under a PPV of 92% was 71%⋅min [2%⋅min-278%⋅min], and the median [IQR] time-weighted average PPV < 92% was 0.3% [0%-0.9%]. Twelve patients (26%) had an area under a PPV of 92% of 0%⋅min, and five patients (11%) had an area under a PPV of 92% of 400%⋅min or higher. The duration of surgery had no clinically important persistent effect on intraoperative PPV or any other sublingual microcirculation variable. The lowest intraoperative PPV was lower than the PPV at incision (estimated difference, -5.3%; 95% confidence interval, -6.3 to -4.4; P < 0.001).

CONCLUSIONS

The area under a PPV of 92% during elective major abdominal surgery was small, indicative of little impairment of sublingual microcirculation. The duration of surgery had no clinically important effect on sublingual microcirculatory variables.

Mitophagy is induced in human engineered heart tissue after simulated ischemia and reperfusion

The paradoxical exacerbation of cellular injury and death during reperfusion remains a problem in the treatment of myocardial infarction. Mitochondrial dysfunction plays a key role in the pathogenesis of myocardial ischemia and reperfusion injury. Dysfunctional mitochondria can be removed by mitophagy, culminating in their degradation within acidic lysosomes. Mitophagy is pivotal in maintaining cardiac homeostasis and emerges as a potential therapeutic target. Here, we employed beating human engineered heart tissue (EHT) to assess mitochondrial dysfunction and mitophagy during ischemia and reperfusion simulation. Our data indicate adverse ultrastructural changes in mitochondrial morphology and impairment of mitochondrial respiration. Furthermore, our pH-sensitive mitophagy reporter EHTs, generated by a CRISPR/Cas9 endogenous knock-in strategy, revealed induced mitophagy flux in EHTs after ischemia and reperfusion simulation. The induced flux required the activity of the protein kinase ULK1, a member of the core autophagy machinery. Our results demonstrate the applicability of the reporter EHTs for mitophagy assessment in a clinically relevant setting. Deciphering mitophagy in the human heart will facilitate development of novel therapeutic strategies.

Significant Stenosis Without Thrombus: Is It the Third Most Common Morphology of Acute Coronary Syndrome?

Background

Significant stenosis without thrombus (SSWT) is sometimes observed in patients with acute coronary syndrome (ACS). However, its incidence and clinical features remains unclear.

Method

This substudy of the TACTICS registry included patients with ACS (n = 702) undergoing emergency percutaneous coronary intervention using optical coherence tomography. Using this registry data, we compared the clinical features of SSWT in patients with ACS. Major adverse cardiac events were defined as cardiac death, nonfatal myocardial infarction, heart failure, or ischemia-driven revascularization at 1 year.

Results

Plaque rupture (PR; n = 411, 59.1%) and plaque erosion (PE; n = 178, 25.6%) were the 2 major morphologies, followed by SSWT (n = 64, 9.1%) and calcified nodule (CN; n = 28, 4.0%). Patients with SSWT were slightly older than those with PR and PE, but younger than those with CN. In the SSWT, non-ST elevation myocardial infarction was the main type of ACS, followed by unstable angina and ST-elevation myocardial infarction (63%, 22%, and 15%, respectively). Lesions were less complex with a lower proportion of type B2 or C, shorter procedure time, lower proportion of multivessel disease, and lower syntax score, which led to a lower incidence of major adverse cardiac events.

Conclusion

SSWT was the third most common morphology of ACS, with clinical features different from those of PR, PE, and CN.

Serum malondialdehyde levels at admission as a predictor of inhospital mortality in patients with acute coronary syndrome

INTRODUCTION AND OBJECTIVE

Malondialdehyde (MDA) is a predictive marker of cardiovascular events in patients with stable angina pectoris. However, there is limited information available regarding this marker in patients with acute coronary syndrome (ACS). The aim of the study was to explore the association of MDA levels with inhospital mortality among patients with ACS.

MATERIALS AND METHODS

The study sample consisted of 556 ACS patients. The leftover plasma samples collected in EDTA vials for troponin T estimation within 24 h of chest pain were used for analysis. Blood samples were collected into tubes for MDA, nitric oxide (NO), inducible nitric oxide synthase (i-NOS), endothelial nitric oxide synthase (e-NOS), total sialic acid (TSA), NT-proBNP, ANP, homocysteine, and cardiac troponin I (cTnI). The blood samples were centrifuged (4000 g , 4 °C) for 10 min, and the obtained serum then kept at -25 °C until the analyses were carried out. The relationship between these markers and inhospital mortality of ACS patients was investigated.

RESULTS

Univariate logistic regression analysis revealed significant correlations among sex, age, creatine, MDA, NT-proBNP, ANP, homocysteine, cTnI, NO, e-NOS, i-NOS, and TSA. Further analysis of these variables using the multivariate logistic regression analysis indicated that age, creatine, MDA, and NT-proBNP were independent predictors. Optimal MDA cutoff value of >33.1 predicted inhospital mortality with 85% sensitivity and 88.17% specificity [AUC: 0.905 (95% CI: 0.878-0.928, P  < 0.001)].

CONCLUSION

We demonstrated that MDA levels were elevated in cases of inhospital mortality among ACS patients and the optimal MDA cutoff value of >33.1 predicted inhospital mortality with 85% sensitivity and 88.17% specificity.

Thoracic pain: From guidelines to clinical practice

Thoracic pain is the most prevalent symptom in patients with cardiovascular diseases. Diagnosis and patient management are guided by the pain attributes, analytical parameters, and several different imaging modalities. Invasive imaging tests and cardiac magnetic resonance are highly relevant in this context, as set out in the 2023 European guidelines for the management of acute coronary syndromes, the 2023 American guidelines for the management of patients with chronic coronary disease, and the 2021 American guidelines for the evaluation and diagnosis of chest pain. This article focuses on the role that these guidelines attribute to non-invasive cardiac imaging (computed tomography and cardiac magnetic resonance) in the management of both acute and chronic coronary syndrome.

Cytokine Hemoadsorption versus Standard Care in Cardiac Surgery Using the Oxiris Membrane: The OXICARD Single-center Randomized Trial

BACKGROUND

Cardiac surgery can lead to dysregulation with a proinflammatory state, resulting in adverse outcomes. Hemadsorption using the AN-69 membrane (Oxiris membrane, Baxter, USA) has the properties to chelate inflammatory cytokines. The authors hypothesized that in patients at high risk of inflammation, the use of the Oxiris membrane could decrease inflammation, preserve endothelial function, and improve postoperative outcomes.

METHODS

The authors conducted a randomized single-center study at Amiens University Hospital (Amiens, France). The study population consisted of adult patients admitted for scheduled cardiac surgery with an expected cardiopulmonary bypass (CPB) time greater than 90 min. The patients were allocated to either the standard group or the Oxiris group. The intervention consisted of using the Oxiris membrane on a Prismaflex device (Baxter, USA) at a blood flow rate of 450 ml/min during CPB. The primary outcome was the assessment of microcirculation on day 1 after surgery by measuring sublingual microcirculation using the microvascular flow index. Microvascular flow index reflects the microcirculation flow type and is graded from 0 to 3 as follows: 0, no flow; 1, intermittent flow; 2, sluggish flow; 3, continuous flow. The secondary outcome was a composite adverse outcome within 30 days after surgery. Cytokines and endothelial biomarkers were measured in all patients at different time points. An intention-to-treat analysis was performed.

RESULTS

From October 2019 to November 2022, the study included 70 patients. Two patients were excluded from the Oxiris group: one patient did not undergo surgery, and one procedure was performed under deep hypothermia. The microvascular flow index did not differ between groups on day 1 from baseline: difference (95% CI) Oxiris minus standard at -0.17 (-0.44 to 0.10); P = 0.2. The occurrence of a composite adverse outcome did not significantly differ between groups (14 [42%] for the Oxiris group vs. 12 [35%] for the standard group; P = 0.7). The overall variation in cytokines and angiopoietins did not significantly differ between groups.

CONCLUSIONS

In patients scheduled for a cardiac surgery with prolonged CPB, the authors could not demonstrate the benefit on microcirculation and major cardiovascular events.

Cardiac Troponin: Fragments of the Future?

Cardiac troponin is the gold standard biomarker for the diagnosis of acute myocardial infarction (AMI). Development of high-sensitivity troponin platforms has revolutionized triage of chest pain patients, but specificity for type 1 AMI remains a clinical limitation. Consequently, differentiating type 1 AMI from other forms of myocardial injury is a common conundrum, heightened by the risks associated invasive coronary angiography. The troponin complex is a dynamic structure comprising of 3 subunits which variably fragment prior to measurement in the blood. Documenting the fragmentation patterns of cardiac troponin may help identify the cause of myocardial injury. This review explores the biology underlying troponin fragmentation and summarizes multiple lines of evidence that it can improve the specificity for diagnosis of type 1 AMI.

Comprehensive profiling of tsRNAs in acute coronary syndrome: expression patterns, clinical correlations, and functional insights

Transfer RNA-derived small RNAs (tsRNAs) have emerged as potential biomarkers of various human diseases. However, the clinical utility and biological functions of tsRNA in acute coronary syndrome (ACS) remain poorly understood. To investigate this, we performed high-throughput small RNA sequencing on peripheral blood monocyte cells (PBMCs) from 24 ACS patients and 12 healthy controls. Our analysis revealed distinct and characteristic expression patterns of tsRNAs in response to ACS, highlighting their potential as disease signatures in human PBMCs. Differentially expressed tsRNAs were validated using RT-qPCR in two independent case-control sets. Among these, tRF-Gly-GCC-06 was significantly upregulated in volunteers with unstable angina (UA) and acute myocardial infarction (AMI) (p < 0.05) and showed a statistically significant positive correlation with the Gensini score (r = 0.353, p < 0.001). Moreover, this tsRNA was independently associated with an increased risk of ACS after adjusting for conventional cardiovascular risk factors (odds ratio (OR) = 1.58, 95% confidence interval (CI): 1.37-1.83, p < 0.001). A series of functional studies showed that tRF-Gly-GCC-06 significantly facilitated macrophage proliferation and migration and modulated inflammation-related gene expression in vitro. This study identified a novel functional gene associated with ACS, tRF-Gly-GCC-06, as a potential clinical biomarker and therapeutic target.

Clinical and Electrocardiographic Characteristics in NSTEMI Patients With Acute Total Occlusion of Culprit Left Circumflex Artery

BACKGROUND

Complete blockage of the culprit coronary artery is associated with 30% of NSTEMI (non-ST-segment elevation myocardial infarction) patients. The culprit vessel in the left circumflex artery (LCX) is more prevalent in this subset of individuals. These people's clinical features and ischemia alterations on electrocardiography (ECG) are unknown. The goals of this study were to examine clinical features and identify predicted ECG abnormalities in NSTEMI patients with complete blockage of the culprit LCX.

METHODS

This study enrolled 5215 consecutive NSTEMI patients' data. A total of 180 people were diagnosed with acute total occlusion of the culprit artery (ATOCA). Based on the culprit vessel, the patients were classified into three groups:ATOCA in the LAD (n = 46), ATOCA in the RCA (n = 38) and ATOCA in the LCX (n = 96). Furthermore, basic clinical data, ECG alterations, and the occurrence of major adverse cardiac events (MACEs) were gathered and examined.

RESULTS

In this single-center investigation, we discovered that ATOCA was more prevalent in patients with NSTEMI in the LCX group. Patients with culprit LCX were more prone to having multivessel coronary disease (p = 0.015), poorer LVEF (p = 0.040), and a lower revascularization success rate (p = 0.019) during hospitalization, although there were no significant differences in MACEs in short and long follow-up. STV5 + STV6 ≥ 2.5 mm (OR = 2.595, 95% CI: 1.297 ~ 5.192) and T-wave imbalance (defined as an upright T-wave in V1 with an amplitude larger than V6 (T1-T6 ≥ 1 mm) recorded from the P-R interval)(OR = 3.871, 95% CI: 1.820 ~ 8.231) were shown to be independent predictors of NSTEMI patients with acute complete blockage of the culprit LCX in multivariate regression analysis.

CONCLUSION

The LCX is the most prevalent culprit vessel with acute complete occlusion in NSTEMI patients, yet it has little effect on clinical outcomes. This subset of patients may be predicted by STV5 + STV6 ≥ 2.5 mm and T-wave imbalance.

Minimally invasive extracorporeal circulation versus conventional cardiopulmonary bypass in patients undergoing cardiac surgery (MiECS): Rationale and design of a multicentre randomised trial

IntroductionThe ultimate answer to the question whether minimal invasive extracorporeal circulation (MiECC) represents the optimal perfusion technique in contemporary clinical practice remains elusive. The present study is a real-world study that focuses on specific perfusion-related clinical outcomes after cardiac surgery that could potentially be favourably affected by MiECC and thereby influence the future clinical practice.MethodsThe MiECS study is an international, multi-centre, two-arm randomized controlled trial. Patients undergoing elective or urgent coronary artery bypass grafting (CABG), aortic valve replacement (AVR) or combined procedure (CABG + AVR) using extracorporeal circulation will be randomized to MiECC or contemporary conventional cardiopulmonary bypass (cCPB). Use of optimized conventional circuits as controls is acceptable. The study design includes a range of features to prevent bias and is registered at clinicaltrials.gov (NCT05487612).ResultsThe primary outcome is a composite of postoperative serious adverse events that could be related to perfusion technique occurring up to 30 days postoperatively. Secondary outcomes include use of blood products, ICU and hospital length of stay (30 days) as well as health-related quality of life (30 and 90 days).ConclusionsThe MiECS trial has been designed to overcome perceived limitation of previous trials of MiECC. Results of the proposed study could affect current perfusion practice towards advancement of patient care.

Short-term exposure to ambient temperature variability and myocardial infarction hospital admissions: A nationwide case-crossover study in Sweden

BACKGROUND

Climate change threatens human health and general welfare via multiple dimensions. However, the associations of short-term exposure to temperature variability, a crucial aspect of climate change, with myocardial infarction (MI) hospital admissions remains unclear.

METHODS AND FINDINGS

This population-based nationwide study employed a time-stratified, case-crossover design to investigate the association between ambient temperature variability and MI hospital admissions among 233,617 patients recorded in the SWEDEHEART registry in Sweden between 2005 and 2019. High-resolution (1 × 1 km) daily mean ambient temperature was assigned to patients' residential areas. Temperature variability was calculated as the difference between the same-day (as the MI event) ambient temperature and the average temperature over the preceding 7 days. An upward temperature shift represents a rise in the current day's temperature relative to the 7-day average, while a downward temperature shift indicates a corresponding decrease. A conditional logistic regression model with distributed lag non-linear model was applied to estimate the association between ambient temperature variability and total MI (encompassing all MI types), ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) hospital admissions at lag 0-6 days. Potential effect modifiers, such as sex, history of diseases, and season, were also examined. The patients had an average age of 70.6 years, and 34.5% of them were female. Our study found that an upward temperature shift was associated with increased risks of total MI (encompassing all MI types), STEMI, and NSTEMI hospital admissions at lag 0 day, with odds ratios (OR, 95% confidence intervals [CIs]) of 1.009 (1.005, 1.013; p < 0.001), 1.014 (1.006, 1.022; p < 0.001), and 1.007 (1.001, 1.012; p = 0.014) per 1 °C increase, respectively. These associations attenuated and became non-significant over lags 1-6 days. Furthermore, a downward temperature shift was associated with increased risks of hospital admissions for total MI (encompassing all MI types) at a lag of 2 days with an OR (95% CI): 1.003 (1.001, 1.005; p = 0.014), and for STEMI at lags 2 and 3 days with ORs (95% CI): 1.006 (1.002, 1.010; p = 0.001) and 1.005 (1.001, 1.008; p = 0.011), per 1 °C decrease, respectively. Conversely, higher downward temperature shifts were associated with decreased risks of total MI (encompassing all MI types) and NSTEMI at lag 0 day. No significant associations were observed at other lag days for downward temperature shifts. Males and patients with diabetes had higher MI hospitalization risks from upward temperature shift exposure, while downward temperature shift exposure in cold seasons posed greater MI hospitalization risks. A methodological limitation was the use of ambient temperature variability as a proxy for personal exposure, which, while practical for large-scale studies, may not precisely reflect individual temperature exposure.

CONCLUSIONS

This nationwide study contributes insights that short-term exposures to higher temperature variability-greater upward or downward temperature shifts-are associated with an increased risk of MI hospitalization. Our finding highlights the cardiovascular health threats posed by higher temperature variability, which are anticipated to increase in frequency and intensity due to climate change.

Clinical impact of visceral adiposity on long-term mortality in patients undergoing coronary artery bypass grafting

INTRODUCTION AND OBJECTIVES

Although visceral adiposity increases cardiovascular risk in the general population, the obesity paradox has been reported in critically ill patients. However, evidence for its prognostic role in patients undergoing coronary artery bypass grafting (CABG) is limited. This study evaluated the prognostic implications of visceral adiposity in patients who underwent CABG using computed tomography-based measurement of visceral fat.

METHODS

A total of 2810 patients who underwent CABG from 2007 to 2017 were analyzed. The study population was classified into 3 groups according to visceral fat area index (VFAI) tertiles. VFAI was calculated as visceral fat area (cm2)/height2 (m2) at the L3 level. The primary outcome was all-cause mortality during follow-up.

RESULTS

Patients in the low VFAI group (lowest tertile) were younger and had a lower body mass index and less subcutaneous fat than those in the high VFAI group (highest tertile). During a median 8.7-year follow-up, VFAI was significantly associated with the risk of mortality in restricted cubic spline curve analysis (HR, 0.94 per 10 increases; 95%CI, 0.91-0.97; P<.001). Patients in the low VFAI group had a higher incidence of long-term mortality than those in the intermediate and high VFAI groups (T1 36.1%, T2 27.2%, and T3 29.1%; T1 vs T2; adjusted HR, 1.36; 95%CI, 1.15-1.61; P<.001; T1 vs T3; adjusted HR, 1.37; 95%CI, 1.16-1.62; P<.001). Similar results were obtained after inverse probability treatment-weighting analysis.

CONCLUSIONS

Low visceral adiposity was associated with an increased risk of long-term mortality in patients who underwent CABG.